Transcript Oral Health with a Focus on Disabilities Powerpoint

Oral Health with
a Focus on Disabilities
June Sadowsky, DDS, MPH
Associate Professor, Dentist Geriatrician
The University of Texas Health Science Center at Houston
School of Dentistry
General Practice and Dental Public Health
1
Dr. June Sadowsky
Dr. June Sadowsky was a member of the HRSA
funded Houston Geriatric Education Center
when this presentation was developed. Dr.
Sadowsky has presented this work to
interprofessional audiences. Please credit her
for the work she provided in the development
and updating of this presentation.
2
Funded By
This project was funded by a grant from the
Health Resources and Services Administration
(HRSA) of the Department of Health and
Human Services. The grant was initially funded
in 2007 with renewed funding for five years
beginning in 2010. (Grant #UB4HP19058). The
grant was successfully completed in June, 2015.
Learning Objectives
• Successful completion will allow the
student to:
– Gain knowledge of the risk factors associated
with oral health and disabilities
– Perceive the oral manifestations of systemic
disease
– Be aware of the diseases and oral management
– Understand some interventions to assist older
adults
4
School of Dentistry
7500 Cambridge, Houston, Texas 77054
5
Major Risk Factors
•
•
•
•
•
Periodontal disease
Caries
Socio-behavioral factors
Environmental factors
Health status
UT Health 2002
6
A Risk Factor for
Cardiovascular Disease
Scannapieco FA. Position Paper Of The American Academy Of Periodontology: Periodontal Disease As A Potential Risk Factor For Systemic
7
Diseases. JPeriodontal. 1998 Jul;69(7)841-50. and Association between periodontitis and anti-cardiolipin antibodies in Buerger disease.
ChenYW etal ,J Clin Periodontol, 2009 Oct;36(10):830-5.
Other Risk Factors
•Medications which reduce saliva flow
•Smoking
•Diabetes
•Cancer
Microsoft
Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000 Volume 62, Issue 1,
pages 59–94, June 2013
8
Link Between Heart Disease
and Gum Disease
• Inflammation is a major risk factor for heart disease, and
periodontal disease may increase the inflammation level
throughout the body. Since several studies have shown that
patients with periodontal disease have an increased risk for
cardiovascular disease, cardiologists and periodontists
developed clinical recommendations and will now see joining
forces to help patients.
• British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81
showed that there was an unexpected correlation between
dental disease and systemic disease (stroke, heart disease,
diabetes).
A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was Published Concurrently In The
Online Versions Of Two Leading Publications, The American Journal Of Cardiology (AJC), A Publication Circulated To 30,000
Cardiologists, And The Journal Of Periodontology (JOP), The Official Publication Of The American Academy Or
Periodontology (AAP). J Periodontol • July 2009. Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of
9
Periodontal Therapy on General Health American Journal of Preventive Medicine Volume 47, Issue 2, Pages 166–174,
August 2014
Caries Risk
• 85% had coronal and/or root caries
• > 75% were taking medications with
hyposalivary side effects
• Lack of fluoride in oral environment
• Saliva very acidic
Caries Activity And Associated Risk Factors In Elderly Hospitalized Population – 15-months Follow-up In
French Institutions Gerodontology, 1999, 6:1; 47-58 Alian AY, McNally ME, Fure S, Birkhed D. Assessment
of caries risk in elderly patients using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463.
10
Environmental Factors
•
•
•
•
•
Societal healthcare
Cultural values
Education
Health promotion
Lifestyle choices
• Stress
• Work–related
environment
• Fluoridated water
• Sugar consumption
• Alcohol use
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Environmental Factors
Mortality (length of life) 50%
Morbidity (quality of life) 50%
Tobacco use
Diet and exercise
Health Outcomes
Health
Behaviors –
30%
Clinical Care 20%
Health Factors
Social and
economic
factors -40%
Alcohol use
Sexual Activity
Access to Care
Quality of Care
Education
Employment
Family and Social Support
Income
Physical
Environment
10%
Policies and Programs
University of Wisconsin Population Health
Institute Model 2012
Community Safety
Environmental Quality
Built Environment
12
Socio-Behavioral Risk Factors
• Human biology
• Vulnerability
• Health care organization
• Public policy changes
• Lifestyle
• Develop personal skills to deal with life
• Recreation
• Use fluoride products
• Environment
• Create more support for elderly
• Income inequality
Google.com/images
1974, Marc Lalonde
13
The common risk factor approach (adapted from
Petersen, 2003)
Petersen PE, Sociobehavioural risk factors in dental caries – international perspectives, Community Dentistry and Oral
Epidemiology Volume 33, Issue 4, pages 274–279, August 2005
14
Health Status
• Tobacco
• Alcohol
• Diet – well balanced
– Decrease sugar intake
– Increase fruit and vegetable
– Vitamin D deficiency
• Fluoride use and plaque removal
twice per day
• Regular dental checkups
Microsoft.com
15
Caries Management By
Risk Assessment
Education
Caries
Risk Assessment
Treatment Plan
Caries Free
http://ncpresby.pbworks.com/f/dental%2016.jpg
Chronic Diseases
•
•
•
•
•
Heart disease
Stroke
Cancer
Chronic respiratory diseases
Diabetes
Microsoft.com
• REPRESENT 60% OF DEATHS
[email protected]
17
Manifestations of
Systemic Disease
18
GI Disease Oral manifestations
• Crohn’s disease
• Ulcerative colitis
– Noncaseating granulomas
– Areas of hemorrhage and
ulceration
– Aphthous ulcers and
chelitis
– Lip, mucosal swelling
– Cobblestone-like gingiva
– Mucosal tags
– Angular chelitis
– Decreased saliva
production and
malabsorption may lead to
dental caries
• GERD
–
–
–
Mouth pH – 5.5
Erosion
Sensitivity
Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s Disease N Engl J Med. June 1 200;
342(22):1644
Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease, Digestive Diseases and Sciences, Vol 19
26,
No.8 (August 1981) Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J Gastroenterol .Apr
Chronic Liver Disease
• Liver Dysfunction
– Coagulation/Vitamin K deficiency
– Gingival bleeding (in the absence of
inflammation)
Microsoft.com
– Petechiae
– Jaundice (bilirubin in submucosa of soft palate)
• Hepatitis - lichen planus, xerostomia,
sialadenitis, erosive lesions
• ALD or Cirrhosis
Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental considerations in patients with
20
liver disease. J Clin Exp Dent.2011;3(2):e127-34.
CD Johnson
Chronic Kidney Disease
• Presence of kidney damage or decreased kidney
function
• Chronic NSAID use
• Oral symptoms
–
–
–
–
–
–
–
–
Ammonia like taste and smell (urea in saliva) and frost on skin
Stomatitis
Gingivitis
Parotitis
Xerostomia
Decreased salivary flow
Google.com/images
Atrophic glossitis
Thirst
Little JW. Dental management of the medically compromised patient. 2013 Elsevier/Mosby, St. Lous
Mo. Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental considerations in patients
with liver disease. J Clin Exp Dent.2011;3(2):e127-34.
21
Anemia
• Occult Blood Loss
• Iron deficiency Anemia
– Chronic inflammation
• B-12 Deficiency (Pernicious Anemia)
– Gastrectomy
• Folate Deficiency
• Oral Manifestations
–
–
–
–
Pale gums
Glossitis (folate and Vitamin B-12 deficiency)
Angular stomatitis (candida infection)
Pica (desire to consume unusual substances, such as ice or dirt)
Spivak JL. Anemia In The Elderly: Time For New Blood In Old Vessels?. Arch Intern Med. Oct 24
2005;165(19):2187-9.
22
Connective Tissue Disorders
• Sjogren’s Syndrome
–
–
–
–
90% females over 50
Sicca syndrome – dry eyes and mouth
Xerostomia
Atrophy of papillae of tongue produces a cobblestone
effect
– Increased incidence of candida infection
– Dental caries
Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008 Jun;35(5):294-6, 298-300, 302.
Klasser GD, Balasubramaniam R Epsein J,Topical review-connective tissue diseases: orofacial manifestations including pain.
23
J Orofac Pain .2007 Summer;21(3):171-84.
Pulmonary Conditions
• COPD
–
–
–
–
–
–
–
90% caused by smoking
Air pollution
Irreversible damage to the airways
Restricts movement
Cough and breathlessness
Soft palate irritation from inhaler use
Dry mucous membranes
• Wegener’s granulomatosis
– Necrotizing vasculitis
– Ulceration and hyperplastic gingival enlargement
Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care
Med. Apr 1 2009;179(7):533-41 Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a
report of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48; quiz 396, 398
24
Diabetes
• 82% of diabetic patients
with severe periodontal
disease have experienced
The number of adults
one or more
age 75+ with
– Major cardiovascular
– 1 million in 2000 to more than 4
million in 2050
– Cerebrovascular
23.1% of patients 60+
– Peripheral vascular
events
OR one of every 4.2 patients
you see over the age of 60! • Compared to only 21% of
diabetics without
5.7 million are
undiagnosed
periodontal disease
• Affects approximately one
in four Americans age 60
and older
•
•
•
•
Centers for Disease Control and Prevention. Public health and aging: trends in aging—United States and worldwide.
MMWR 2003;52(06):101-106 Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J Periodontol
2006 Aug;77(8):1289-130
http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages
25
Diabetes
• Uncontrolled diabetics exhibit higher levels
of collagenase that can degrade periodontal
tissues(Ryan 2003, Salvi 1997)
• Periodontal disease results in higher proinflammatory cytikine TNF-‫ ﻪ‬that causes
insulin resistance(Grossi 1998)
• Diabetic patients who have full-mouth
disinfections every three months showed
significant reductions in their HbA1c serum
levels (blood glucose) (Lang 2008)
26
Arthritis
• Leading cause of
disability
• Affects 8 million
• Severely limits ability
to perform Activities
of Daily Living (ADL’s)
• Loss of Range of
Motion
•
•
•
•
•
Stiffness
Joint Deformity
Overweight, Fatigue
Unexplained fever
May affect TMJ
(temporomandibular
joint)
Rutger Persson G. Rheumatoid arthritis and periodontitis: inflammatory and infectious connections: review of
the literature. J Oral Microbiol 2012; 4:10.
27
Arthritis
• Osteoarthritis – common
• Joint Pain,
• Rheumatoid - + RF in
tenderness and
blood
inflammation
• Gout – Uric acid
• CRP=C-Reactive
• Beer, sardines, organ meats
Protein in blood
serum produced in
the liver during
acute inflammation
or infection
Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25
Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dental
Res 2012; 91:914–920.
28
Arthritis and Periodontal Disease
• Patients referred for periodontal treatment
– prevalence of self-reported rheumatoid arthritis was
3.95%
– Significantly higher than that seen in patients not
referred for periodontal treatment (0.66%)
– that reported in the general population (1%).
Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth loss and incident rheumatoid
arthritis: results from the First National Health and Nutrition Examination Survey and its epidemiological follow-up
study. J Clin Periodontol 2011; 38:998–1006
29
Arthritis and Periodontal Disease
• Of those referred patients with rheumatoid
arthritis, 62.5%
– advanced forms of periodontal disease
– self-reported prevalence of cardiovascular disease and
diabetes mellitus
Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease and risk
30
of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804
Arthritis and Periodontal Disease
• Conclusions: there is good evidence to
suggest that individuals with moderate to
severe periodontal disease are at higher risk of
suffering from rheumatoid arthritis and vice
versa.
Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000 Arkema EV, Karlson EW, Costenbader KH.
A prospective study of periodontal disease and risk of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804
31
Osteoporosis
• People with osteoporosis are
much more likely to lose
their teeth due to bone loss
in the jaw.
• Good homecare is even
more important to help
prevent tooth loss.
Osteoporosis Treatment
• Bone-replacing cells in bone
are suppressed and if an
extraction, bone may not
heal.
Mattson JS1, Cerutis DR, Parrish LC.Osteoporosis: a review and its dental implications.
Compend Contin Educ Dent. 2002 Nov;23(11):1001-4
Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2005 Sep;100(3):349-56.
32
Oral Manifestation of
Viral Diseases
• Herpes
• Zoster (Shingles)
Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007
33
Oral Manifestation of
Viral Diseases
• Human papillomavirus
• Squamous cell papilloma and verruca
vulgaris
• Human immunodeficiency virus
• Plantar warts on hands
Schubert MM. Oral manifestations of viral infections in immunocompromised patients. Curr Opin Dent
1991;1:384-97. Bouquot JE.Herpes Zoster, Texas Dental Journal, 2007
34
Head and Neck Cancer
• Incidence oral and pharyngeal cancer in 2012 in the US
•
40,250 new cases (28,540 in men and 11,710 in women)
• Estimated Deaths in 2012
– 7,850 people (5,440 men and 2,410 women)
• Careful monitoring of the oral cavity with strict
application of preventive measures
•
•
•
•
•
Lower radiation doses or intensity-modulated radiotherapy (IMRT)
Use of shielding
Reduction in the use of toxic drugs
Improved oral instructions and expectations
Completion of dental treatment before beginning cancer care benefits the
patient greatly
http://www.cancer.org/acs/groups/cid/documents/webcontent/003128-pdf.pdf
35
Drug Induced Oral Manifestations
• Apthous stomatitis
– Canker sores
• Lichen Planus
–
–
–
–
–
ACE inhibitors
Beta-blockers
NSAID’s
Diuretics
hydroxychloroquine
• Gingival Enlargement
(hyperplasia)
• Dry Mouth/Xerostomia
(hyposalivation)
–
–
–
–
–
Single most adverse effect
Anticholinergic effect
Alters taste
Difficulty eating , swallowing
Treatment
•
•
•
Increased hydration
Artificial saliva
Procholinergic agents
– Phenytoin
– Ca+ Channel Blockers
– Cyclosporine
Chuang TY, Stitle L, Brashear R, Lewis C. Hepatitis C Virus And Lichen Planus: A Case Control Study Of 340
Patients. J Am Acad Dermatol, Nov 1999;4195):787-9
Abdollahi M, Radfar M; A review of drug induced manifestations, J Contemp Dent Prac, 2003(2)1:10-31
36
Dry Mouth
CD Johnson
37
Drug Induced Oral Manifestations
• Stevens-Johnson
Syndrome
– 3 weeks after meds
– Rash to purpuric
macules
– 50 % oral
•
•
•
•
Sulfonamides
Penicillin
Phenytoin
Phylbutazone
• Drug -induced
Neutropenia
– Ulcers on gingiva
• Fungal Infections
– Radiation
– Chemotherapeutics
– Immunosuppressives
Bologna JL, Jorizzo, JL, Papini, RP, Dermatology. Spain: Mosby 2003
38
Candidiasis
39
Diseases
and
Oral Management
40
Disease and Oral Management
• Alzheimer’s/dementia
• Dental Management Of Patients With Alzheimer's Disease And
Other Dementias (Ronald L Ettinger July 2000volume 17, Issue 1pages X–xi, 1–64)
• Alzheimer's Disease And Dental Management (Hümeyra Kocaelli Etal
Oral Surg, Oral Med, Oral Path, Oral Rad and Endo Vol 93 5, May 2002, Pages 521-524)
• Stroke
• Movement disorders
• Parkinson’s
• Oral Health and Peripheral Arterial Disease. Hung HC, Circulation. 2003;
107: 1152-1157
• Oral care for patients with cardiovascular disease and stroke (Louis F.
Rose LF, Etal. J Am Dent Assoc, Vol 133, No suppl1, 37S-44S. 2002)
• Can’t do ADL’s
41
Disease and Oral Management
• Continued growth of population over 65
• Globally oral health is poor in elderly
– Prevention is not emphasized
– Those in dependent situations have few oral
caregivers
• More people are keeping their teeth
longer means more teeth at risk
World Wide Public Health Of Elderly - Improving The Oral Health Of Older People: The Approach Of The WHO Global
Oral Health Programme Poul Erik Petersen, Tatsuo Community Dentistry And Oral Epidemiology Volume 33, Issue 2,
Pages 81–92, April 2005
42
Disease and Oral Management
• Long –term care
– Patient consent issues
– Seventy percent of patients in long-term care
facilities had unacceptable levels of oral hygiene (Kiyak
et al. 1987, McIntyre et al. 1986)
– lack of knowledge about oral care
• Homebound
• Hospice
• Oral Cancer patients
– Majority elders
Kiyak HA. An explanatory model of older persons’ use of dental services: implications for health policy. Med Care 1987;25:936–52.
MacEntee MI, Weiss R, Waxler-Morrison NE, Morrison BJ. Factors influencing oral health in long term care facilities. Community
Dent Oral Epidemiol 1987;15: 314–6.
43
Other Barriers to Dental Care
• Access
– Transportation
• Housing
– Live in abandoned car
• Legal
– VA Benefit
– Alien status
44
Interventions to
Assist Older
Adults
45
Management Options
• Education
– Entities caring for seniors
– Students and faculty to retain patients
• Linkage to Community Resources
–
–
–
–
Transportation
Mental Health
Living
Caregiving
• Outreach to Seniors concerning dental needs
46
Management Options
• Education
– Caregiver training video
designed for nursing
homes, assisted living
facilities, and
individuals.
– Make a donation of one
to a
facility near you.
47
Dental Management
• Make all offices elder friendly
• Literacy alert
– Bigger print
– Language easy to understand
• Educate caregivers
• Alter toothbrushes
• Forms for daily documentation of oral
care
• Mobile/portable dental teams
48
References
•
•
•
•
•
•
•
•
Scannapieco FA. Position Paper Of The American Academy Of Periodontology:
Periodontal Disease As A Potential Risk Factor For Systemic Diseases J. Periodontal. 1998
Jul;69(7)841-50
ChenYW etal . Association between periodontitis and anti-cardiolipin antibodies in
Buerger disease. J Clin Periodontol, 2009 Oct;36(10):830-5.
Genco RJ, Borgnakke WS. Risk factors for periodontal disease. Periodontology 2000
Volume 62, Issue 1, pages 59–94, June 2013
A Consensus Paper On The Relationship Between Heart Disease And Gum Disease Was
Published Concurrently In The Online Versions Of Two Leading Publications, The
American Journal Of Cardiology (AJC), A Publication Circulated To 30,000 Cardiologists,
And The Journal Of Periodontology (JOP), The Official Publication Of The American
Academy Or Periodontology (AAP). J Periodontol • July 2009
Jeffcoat MK, Jeffcoat RL, Gladowski PA, Bramson JB, Blum, Impact of Periodontal Therapy
on General Health American Journal of Preventive Medicine Volume 47, Issue 2,
Pages 166–174, August 2014
British Medical Journal (BMJ), 1989 Mar 25;298(6676):779-81
Caries Activity And Associated Risk Factors In Elderly Hospitalized Population – 15months Follow-up In French Institutions Gerodontology, 1999, 6:1; 47-58
Alian AY, McNally ME, Fure S, Birkhed D. Assessment of caries risk in elderly patients
using the Cariogram model. J Can Dent Assoc. 2006;72(5):459 -463.
49
References
•
•
•
•
•
•
•
•
•
•
•
University of Wisconsin Population Health Institute Model 2012
1974, Marc Lalonde
[email protected]
Stricker T, Braegger CP, Images In Clinical Medicine. Oral Manifestations Of Crohn’s
Disease N Engl J Med. June 1 200; 342(22):1644
Beitman RG, Frost SS, Roth JL. Oral Manifestations of Gastrointestinal Disease,
Digestive Diseases and Sciences, Vol 26, No.8 (August 1981)
Daley TD, Armstrong JE. Oral Manifestations of Gastrointestinal Diseases, Can J
Gastroenterol .Apr 2007;21(4):241-4
Bagan JV, Aguirre JM etal; Oral lichen planus and chronic liver disease: A clinical and
morphometric study of the oral lesions in relation to transaminase elevation; Oral
Surgery, Oral Medicine, Oral Pathology Volume 78, Issue 3, September 1994, Pages
337–342
Cruz-Pamplona M, Margaix-Muñoz M, Gracia Sarrión-Pérez MG.Dental
considerations in patients with liver disease. J Clin Exp Dent.2011;3(2):e127-34.
Little JW. Dental management of the medically compromised patient. 2013
Elsevier/Mosby, St. Lous Mo.
Porter S, Scully C. Connective tissue disorders and the mouth. Dent Update 2008
Jun;35(5):294-6, 298-300, 302.
Klasser GD, Balasubramaniam R Epsein J, Topical review-connective tissue diseases:
orofacial manifestations including pain. J Orofac Pain. 2007 Summer;21(3):171-84.
50
References
•
•
•
•
•
•
•
•
•
Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary
disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41
Stewart C, Cohen D, etal. Oral manifestations of Wegener's granulomatosis: a report
of three cases and a literature review. J Am Dent Assoc. 2007 Mar;138(3):338-48;
quiz 396, 398
Centers for Disease Control and Prevention. Public health and aging: trends in
aging—United States and worldwide. MMWR 2003;52(06):101-106
Measley BL, Oates TW. Periodontal Inflammation And Diabetes Mellitus. J
Periodontol 2006 Aug;77(8):1289-130
http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#allages
The influence of diabetes on periodontal disease, Ryan ME, Carnu O, Kamer A.
JADA, Vol. 34, (10): 34S-40S.
Salvi G, Yalda B, Collins J, et al. Inflammatory mediator response as a potential risk
marker for periodontal diseases in insulin dependent diabetes mellitus patients. J
Periodontol 1997;68(2):127:35.
Grossi SG, Genco RJ: Periodontal disease and diabetes mellitus: a two-way
relationship. Ann Periodontol 3:51–61, 1998
Lang NP, Tan WC, Krahenmann MA, Zwahlen M. A systematic review of the effects
of full-mouth debridement with and without antiseptics in patients with chronic
periodontitis. J Clin Periodontol. 2008 Sep;35(8 Suppl):8-21.
51
References
•
•
•
•
•
•
•
•
Dye BA. Global periodontal disease epidemiology. Periodontol 2000 2012; 58:10–25
Eke PI, Dye BA, Wei L, et al. Prevalence of periodontitis in adults in the United
States: 2009 and 2010. J Dental Res 2012; 91:914–920.
Demmer RT, Molitor JA, Jacobs DR Jr, Michalowicz BS. Periodontal disease, tooth
loss and incident rheumatoid arthritis: results from the First National Health and
Nutrition Examination Survey and its epidemiological follow-up study. J Clin
Periodontol 2011; 38:998–1006
Mercado, etal Journal of Clinical Periodontology. 27(4):267-272, April 2000
Arkema EV, Karlson EW, Costenbader KH. A prospective study of periodontal disease
and risk of rheumatoid arthritis. J Rheumatol 2010; 37:1800–1804
Mattson JS, Cerutis DR, Parrish LC. Osteoporosis: a review and its dental
implications. Compend Contin Educ Dent. 2002 Nov;23(11):1001-4
Dervis E. Oral implications of osteoporosis. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2005 Sep;100(3):349-56.
Zachariasen RD, Oral manifestations of menopause. Compendium, 1993,
14(12):1584, 1586-91
52
Questions
• June M. Sadowsky, DDS, MPH
– 713-500-4064
– [email protected]
• Images
– HoustonGEC would like to thank:
• Microsoft images
• Google.com images
• UTHEALTH School of Dentistry
• New Patient Information
– UTHealth School of Dentistry
– 713-486-4000
53